Cancer advocacy in residency education: From principles to competencies.

INTRODUCTION: The global cancer burden is increasing. Current global evidence indicates there will be a 47% rise of cancer cases for the period 2020-2040. The cancer rate differential also is evident within countries and regions. Efforts have been used to reduce the health disparities; however, the inequity prevails. One potential way to help reduce the disparity is through advocacy by physicians. METHODS: Two recent systematic review articles on advocacy among physicians note that physicians are unlikely to be taught advocacy in medical education, and also note there are no advocacy competencies or skill sets that are either taught or valued in medical education. We explore literature and develop a model to understand the components of advocacy in medical education, specifically in resident training. We follow the model's main components by examining principles of advocacy, relevant domains of advocacy, and competencies and values for advocacy education. RESULTS: Four ethical principles of advocacy education are identified: beneficence, non-maleficence, autonomy, and justice. These principles must be applied in meaningful, culturally sensitive, respectful, and promotion of the well-being ways. Three domains are identified: the practice domain (provider-patient interaction), the community domain (provider-community collaboration), and the health policy domain (the larger social environment). Advocacy occurs differently within each domain. Finally, competencies in the form of knowledge, skills, and values are described. We present a table noting where each competency occurs (by domain) as well as the value of each knowledge and skill. POLICY SUMMARY: The significance of including advocacy instruction in medical education requires a change in the current medical education field. Besides valuing the concept of including advocacy, principles, domains, and competencies of inclusion are critical. In summary, we encourage the inclusion of advocacy education in resident medical programs so physicians become competent medical providers at diverse levels of society.

Pronounced cortical porosity and sex-specific patterns of increased bone and osteocyte lacunar mineralization characterize the human distal fibula with aging.

The high occurrence of distal fibula fractures among older women suggests a potential link to impaired bone health. Here we used a multiscale imaging approach to investigate the microarchitecture, mineralization, and biomechanics of the human distal fibula in relation to age and sex. Micro-computed tomography was performed to analyze the local volumetric bone mineral density and various microarchitectural parameters of the trabecular and the cortical compartment. Bone mineral density distribution and osteocyte lacunar parameters were quantified using quantitative backscattered electron imaging in periosteal, endocortical, and trabecular regions. Additionally, cortical hardness and Young's modulus were assessed by nanoindentation. While cortical porosity strongly increased with age independent of sex, trabecular microarchitecture remained stable. Notably, nearly half of the specimens showed non-bony hypermineralized tissue located at the periosteum, similar to that previously detected in the femoral neck, with no consistent association with advanced age. Independent of this finding, cortical and trabecular mineralization, i.e., mean calcium content, as well as endocortical tissue hardness increased with age in males but not females. Importantly, we also observed mineralized osteocyte lacunae that increased with age specifically in females. In conclusion, our results indicate that skeletal aging of the distal fibula is signified not only by pronounced cortical porosity but also by an increase in mineralized osteocyte lacunae in females. These findings may provide an explanation for the increased occurrence of ankle fractures in older women.

Alterations in compositional and cellular properties of the subchondral bone are linked to cartilage degeneration in hip osteoarthritis.

OBJECTIVE: The subchondral bone is an emerging regulator of osteoarthritis (OA). However, knowledge of how specific subchondral alterations relate to cartilage degeneration remains incomplete. METHOD: Femoral heads were obtained from 44 patients with primary OA during total hip arthroplasty and from 30 non-OA controls during autopsy. A multiscale assessment of the central subchondral bone region comprising histomorphometry, quantitative backscattered electron imaging, nanoindentation, and osteocyte lacunocanalicular network characterization was employed. RESULTS: In hip OA, thickening of the subchondral bone coincided with a higher number of osteoblasts (controls: 3.7 ± 4.5 mm-1, OA: 16.4 ± 10.2 mm-1, age-adjusted mean difference 10.5 mm-1 [95% CI 4.7 to 16.4], p < 0.001) but a similar number of osteoclasts compared to controls (p = 0.150). Furthermore, higher matrix mineralization heterogeneity (CaWidth, controls: 2.8 ± 0.2 wt%, OA: 3.1 ± 0.3 wt%, age-adjusted mean difference 0.2 wt% [95% CI 0.1 to 0.4], p = 0.011) and lower tissue hardness (controls: 0.69 ± 0.06 GPa, OA: 0.67 ± 0.06 GPa, age-adjusted mean difference -0.05 GPa [95% CI -0.09 to -0.01], p = 0.032) were detected. While no evidence of altered osteocytic perilacunar/canalicular remodeling in terms of fewer osteocyte canaliculi was found in OA, specimens with advanced cartilage degeneration showed a higher number of osteocyte canaliculi and larger lacunocanalicular network area compared to those with low-grade cartilage degeneration. Multiple linear regression models indicated that several subchondral bone properties, especially osteoblast and osteocyte parameters, were closely related to cartilage degeneration (R2 adjusted = 0.561, p < 0.001). CONCLUSION: Subchondral bone properties in OA are affected at the compositional, mechanical, and cellular levels. Based on their strong interaction with cartilage degeneration, targeting osteoblasts/osteocytes may be a promising therapeutic OA approach. DATA AND MATERIALS AVAILABILITY: All data are available in the main text or the supplementary materials.

Cholesteatoma Severely Impacts the Integrity and Bone Material Quality of the Incus.

Cholesteatoma can lead to progressive destruction of the auditory ossicles along with conductive hearing loss but precise data on the microstructural, cellular, and compositional aspects of affected ossicles are not available. Here, we obtained incus specimens from patients who had cholesteatoma with conductive hearing loss. Incudes were evaluated by micro-computed tomography, histomorphometry on undecalcified sections, quantitative backscattered electron imaging, and nanoindentation. Results were compared with two control groups taken from patients with chronic otitis media as well as from skeletally intact donors at autopsy. The porosity of incus specimens was higher in cholesteatoma than in chronic otitis media, along with a higher osteoclast surface per bone surface. Histomorphometric assessment revealed higher osteoid levels and osteocyte numbers in cholesteatoma incudes. Incudes affected by cholesteatoma also showed lower matrix mineralization compared with specimens from healthy controls and chronic otitis media. Furthermore, the modulus-to-hardness ratio was higher in cholesteatoma specimens compared with controls. Taken together, we demonstrated increased porosity along with increased osteoclast indices, impaired matrix mineralization, and altered biomechanical properties as distinct features of the incus in cholesteatoma. Based on our findings, a possible impact of impaired bone quality on conductive hearing loss should be further explored.

Fatal outcomes of endoscopy: an analysis from the coroner's point of view.

Background and study aims This study was designed to provide a profound analysis of fatalities associated with endoscopic procedures. Methods Protocols of all autopsies performed within 20 years in a large Department of Forensic Medicine were retrospectively analyzed to identify all fatalities directly related to an endoscopic procedure. Data were further specified focusing on the type of endoscopy and the final cause of death. Results Of 22,615 autopsies performed between January 2000 and September 2019, 86 deaths were identified as complications of an endoscopic procedure. The average age of these 86 patients was 70.9 years (66.4 (range, 26-89) in males (n = 35) and 74.1 years (range, 22-94) in females (n = 51)). Endoscopic procedures included 29 endoscopic retrograde cholangeopancreatographies (ERCPs), 27 colonoscopies, 18 percutaneous endoscopic gastrostomy (PEG) tube placements, six gastroscopies, two upper endosopic ultrasonographies, and four transesophageal echocardiographies. ERCPs, colonoscopy and PEG procedures together accounted for 74 of 86 (86 %) endoscopy-related deaths. Focusing on the single procedures, post-ERCP pancreatitis (14/29, 48 %), colonoscopy-associated perforation (24/27, 89 %), and peritonitis after PEG placement (16/18, 88 %) were the most common causes of death. Conclusions Even in the thought-to-be-safe and screening endoscopic procedures fatalities do occur. This study gives an overview of endoscopy-related fatalities, stressing the role of ERCP, colonoscopy, and PEG.

Access disparities and underutilization of germline genetic testing in Chilean breast cancer patients.

PURPOSE: Latin American reports on genetic cancer risk assessments are scarce. In Chile, current breast cancer (BC) guidelines do not define strategies for germline genetic testing. Our study sought to quantify the disparities in access to genetic testing in Chilean BC patients, according to international standards and their clinical characteristics to explore improvement strategies. METHODS: Retrospective analysis of invasive BC databases including patients treated in a Public Hospital (PH) and in an Academic Private Center (AC) in Santiago, Chile between 2012 and 2021. RESULTS: Of 5438 BC patients, 3955 had enough data for National Comprehensive Cancer Network (NCCN) categorization. From these, 1911 (48.3%) fulfilled NCCN criteria for germline testing, of whom, 300 were tested for germline mutations and 268 with multigene panels. A total of 65 pathogenic variants were found in this subset. As expected, BRCA1/2 mutations were the most frequent (17.7%). Access to genetic testing was higher in AC versus PH (19.6% vs. 10.3%, p = 0.0001). Other variables associated with germline genetic testing were BC diagnosis after 2018, being 45 years old or younger at diagnosis, BC family history (FH), FH of ovarian cancer, non-metastatic disease, and triple-negative subtype. CONCLUSION: In our cohort, 15% of BC patients who met NCCN criteria for germline testing were effectively tested. This percentage was even lower at the PH. Current recommendations encourage universal genetic testing for BC patients; however, our findings suggest that Chile is far from reaching such a goal and national guidelines in this regard are urgently needed. To our knowledge, this is the first study of its kind in Chile and Latin America.

[One and a half years of e-scooters in Hamburg]. / Eineinhalb Jahre E-Scooter ­ Zwischenbilanz in Hamburg: Teil 2: Unfallcharakteristika.

Background: Since the spread of the so-called electric scooters (e-scooters) through rental services in Hamburg as of June 2019, accidents due to the use of this means of transportation have been regularly registered. The most frequent injury patterns among e­scooter riders involved accidents concerning the upper extremities and the head. There was a relevant accumulation of drunk drivers among the injured persons. Objective: The aim of the study is to compare injury patterns in drunk versus non-drunk e­scooter riders who had an accident. Material and methods: Data from the Department of Trauma Surgery at the University Medical Center Hamburg-Eppendorf were retrospectively analyzed for accidents involving e­scooters and the resulting injury patterns. For this purpose, the gender, age, injury pattern of the persons, the course of the accident, and information on previous alcohol consumption were recorded descriptively for the period from June 2019 to December 2021. Results: Drivers were on average 32 (interval: 15-88 years) years old and those under the influence of alcohol were predominantly male (69.9%). Accidents occurred mainly in summer and at night. Common injury patterns were injuries to the face, head, and extremities. Conclusion: It should be noted that injuries to the face and head occurred more frequently under the influence of alcohol than in the cohort without alcohol. Education about the health and legal consequences of riding an e­scooter under the influence of alcohol should be provided to all users. In addition, wearing a helmet or banning driving at night are possible measures to reduce accidents associated with drunk riding.

Comparison of Arthroscopic versus Open Placement of the Fibular Tunnel in Posterolateral Corner Reconstruction.

INTRODUCTION: Precise fibular tunnel placement in posterolateral corner (PLC) reconstruction is crucial in restoring rotational and lateral stability. Despite the recent progress of arthroscopic PLC reconstruction techniques, landmarks for arthroscopic fibular tunnel placement and a comparison to open tunnel placement have not yet been described. This study aimed to (1) identify reasonable soft-tissue and bony landmarks, which can be identified by either arthroscopy, fluoroscopy, or open surgery in anatomic fibular tunnel placement and (2) to compare accuracy and reliability of arthroscopic fibular tunnel placement with open surgery. MATERIALS AND METHODS: In a retrospective study, 41 magnetic resonance images (MRIs) of the knee were analyzed with emphasis on distances of an ideal anatomic fibular tunnel to 11 soft-tissue and bony landmarks. Subsequently, in eight cadaver knees, the ideal fibular tunnel was created arthroscopically and with a standard open technique from antero-latero-inferior to postero-medio-superior with a 2-mm K-wire. Positions of both tunnels were compared on postinterventional computed tomography scans. RESULTS: Based on MRI measurements, the anatomic tunnel entry should be 14.50 (±2.18) mm distal to the tip of the fibular styloid and 10.76 (±1.37) mm posterior to the anterior edge of the fibula. The anatomic fibular tunnel exit was located 12.89 (±2.35) mm below the tip of the fibular head. Arthroscopic fibular tunnel placement was reliable in all cases. Instead, in five out of the eight cases with open surgery, the fibular tunnel crossed the defined safety distance to the closest cortical edge/tibiofibular joint (distance < 8 mm). CONCLUSIONS: Reliable soft-tissue and bony landmarks of the fibular head allow arthroscopic anatomic fibular tunnel placement in PLC surgery, which shows a lower risk of tunnel malposition compared with open surgical techniques. Future studies will have to show whether clinical results of arthroscopic PLC reconstruction are in line with this study's technical results. LEVEL OF EVIDENCE: Level III.

Clinical characteristics, risk factors, and outcomes in Chilean triple negative breast cancer patients: a real-world study.

BACKGROUND: Latin American (LA) studies on triple-negative breast cancer (TNBC) and their characteristics are scarce. This forces physicians to make clinical decisions based on data obtained from studies that include non-Hispanic patients. Our study sought to obtain local epidemiological data, including risk factors and clinical outcomes from a Chilean BC registry. METHODS: This was a retrospective population-cohort study that included patients treated at a community hospital (mid-low income) or an academic private center (high income), in the 2010-2021 period. Univariate and multivariate analyses were performed to identify prognostic factors associated with survival. RESULTS: 647 out of 5,806 BC patients (11.1%) were TNBC. These patients were younger (p = 0.0001) and displayed lower rates of screening-detected cases (p = 0.0001) compared to non-TNBC counterparts. Among TNBC patients, lower income (i. e., receiving treatment at a community hospital) was associated with poorer overall survival (HR: 1.53; p = 0.0001) and poorer BC specific survival (HR: 1.29; p = 0.004). Other risk factors showed no significant differences between TNBC and non-TNBC. As expected, 5-year OS was significantly shorter on TNBC versus non-TNBC patients (p = 0.00001). In our multivariate analyses TNBC subtype (HR: 2.30), locally advanced stage (HR: 7.04 for stage III), lower income (HR: 1.64), or non-screening detected BC (HR: 1.32) were associated with poorer OS. CONCLUSION: To the best of our knowledge, this is the largest LA cohort of TNBC patients. Interestingly, the proportion of TNBC among Chileans was smaller compared to similar studies within LA. As expected, TNBC patients had poorer survival and higher risk for early recurrence versus non-TNBC. Other relevant findings include a higher proportion of premenopausal patients among TNBC. Also, mid/low-income patients that received medical attention at a community hospital displayed lower survival versus private health center counterparts.

Long-term Mammography Utilization after an Initial Randomized Intervention Period by all Underserved Chilean Women in the Clinics.

Chile has one of the highest rates of breast cancer in Latin America. Mammography rates among women, especially those of low socioeconomic status (SES), are thought to contribute to high breast cancer morbidity and mortality. A successful randomized controlled trial among women aged 50 to 70 in a low-SES primary care clinic in Chile led to a significant increase in mammography screening rates in a two-year intervention trial. This study assesses the sustainability of the intervention after ten years and identifies factors that might have been associated with a long-term effect using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The mammography rates among women aged 50 to 70 in the low-SES intervention clinic were compared to two populations of women aged 50 to 70 from middle-SES clinics and to national data. Qualitative data were used to answer questions of adoption, implementation, and maintenance, while quantitative data assessed the reach and effectiveness. After ten years, low-SES women at the intervention clinic maintained significantly higher mammography screening rates vs. middle-SES women at the comparison clinics (36.2% vs. 30.1% and 19.4% p < 0.0001). Women of a low SES at the intervention clinic also had significantly higher screening rates compared to women of a low SES at a national level (44.2% vs. 34.2% p < 0.0001). RE-AIM factors contributed to understanding the long-term difference in rates. Mailed contact, outreach interventions, and the integration of health promoters as part of the Community Advisory Board were important factors associated with the effects observed. This study provides information on factors that could contribute to reducing the social gap on breast cancer screening.

Robotic Tissue Sampling for Safe Post-Mortem Biopsy in Infectious Corpses.

In pathology and legal medicine, the histopathological and microbiological analysis of tissue samples from infected deceased is a valuable information for developing treatment strategies during a pandemic such as COVID-19. However, a conventional autopsy carries the risk of disease transmission and may be rejected by relatives. We propose minimally invasive biopsy with robot assistance under CT guidance to minimize the risk of disease transmission during tissue sampling and to improve accuracy. A flexible robotic system for biopsy sampling is presented, which is applied to human corpses placed inside protective body bags. An automatic planning and decision system estimates optimal insertion point. Heat maps projected onto the segmented skin visualize the distance and angle of insertions and estimate the minimum cost of a puncture while avoiding bone collisions. Further, we test multiple insertion paths concerning feasibility and collisions. A custom end effector is designed for inserting needles and extracting tissue samples under robotic guidance. Our robotic post-mortem biopsy (RPMB) system is evaluated in a study during the COVID-19 pandemic on 20 corpses and 10 tissue targets, 5 of them being infected with SARS-CoV-2. The mean planning time including robot path planning is 5.72±167s. Mean needle placement accuracy is 7.19± 422mm.

Post-mortem histopathology of pituitary and adrenals of COVID-19 patients.

BACKGROUND: Knowledge of the exact organ manifestation is essential for a comprehensive understanding of COVID-19 infection. Here, the histopathological changes in the pituitary and adrenal glands were analyzed. METHODS: In this series, the formalin-fixed tissues of 63 pituitary glands and 50 adrenal glands were examined. We performed HE and PAS staining and examined COVID-19 nucleocapsid antibody immunohistochemically in the pituitary glands and adrenals. RESULTS: Histologically, there was no evidence of COVID-19-specific changes in the pituitary and adrenal glands. Large pituitary necrosis may be interpreted as a shock reaction. Independent of infection, we found one T-cell lymphoma, two adenomas, and four Rathke-type cysts in the pituitary glands, and 70% of the adrenal glands showed decreased lipid content and an increase in compact cells as a stress response. In addition, a cortical adenoma in one adrenal gland and small cortical nodules in three adrenal glands were detected independently of COVID-19. CONCLUSION: Pituitary and adrenal glands do not appear histologically predominant in the course of COVID-19.

Pulmonary cement embolism is frequently observed but not a contributing factor for death in patients with cemented total hip and knee arthroplasty: a postmortem study.

PURPOSE: Bone cement is frequently used for implant fixation in orthopaedic surgery. The occurrence of pulmonary cement embolism (PCE) in hip and knee arthroplasty has been described previously, but the exact extent and frequency have not been adequately studied. A postmortem cohort provides a unique opportunity for a more detailed analysis of this phenomenon. METHODS: Through retrospective analysis of whole-body computed tomography (CT) scans and autopsy protocols, we identified 67 cases with previous cemented total hip or knee arthroplasties. A grading system originally developed for PCE after cemented spine procedures was used. Findings were compared with two control groups: 35 individuals with previous cementless total joint arthroplasty as well as 25 individuals without evidence of prostheses. RESULTS: PCE was detected in 46.3% of the cases: grade 1 (31.3%), grade 2 (10.5%), and grade 3 (4.5%). No statistically significant difference was found between hip and knee arthroplasties in terms of PCE frequency. Importantly, none of the autopsy reports listed PCE as a cause of death or a contributing factor for the patients' death. In the two control groups, only one case per group was classified as grade 1 PCE, while the remaining cases did not show any evidence of PCE. CONCLUSION: The presented data reveal a high frequency of PCE in hip and knee arthroplasties, which is almost identical to previous findings in patients with cement-augmented interventions in the spine. This way, our results underline the relevance of PCE after arthroplasty, suggesting an adaptation of surgical methods to minimize this complication.

Visualization of the distal tibial plafond articular surface using four established approaches and the efficacy of instrumented distraction: a cadaveric study.

PURPOSE: Direct visualization is a very effective method in accomplishing adequate articular surface reconstruction in fracture repair. This study investigates distal tibial plafond articular surface visibility using the anteromedial, anterolateral, posteromedial, and posterolateral approaches, the effect of instrumented distraction on visibility, and which zones of the articular surface are visible for each approach. METHODS: The anteromedial, anterolateral, posteromedial, and posterolateral approaches to the distal tibial plafond were performed on 16 cadaveric ankle specimens. The articular surface visualization for each approach was marked using an electrocautery device with manual and instrumented distraction. Articular surface visualization was photographically documented. Digital axial segmentation and quantitative analysis of the visualized distal tibial plafond articular surface were performed. RESULTS: With manual distraction, distal tibial plafond articular surface visualization, expressed in percent of overall articular surface, was limited to 9% (SD ± 9) for the anteromedial, 24% (SD ± 18) for the anterolateral, 26% (SD ± 10) for the posteromedial, and 30% (SD ± 18) for the posterolateral approaches. Using instrumented distraction significantly improved articular surface visualization in all instances (p < 0.001). The anteromedial approach visible articular surface increased to 63% (SD ± 13), the anterolateral to 72% (SD ± 22), the posteromedial to 62% (SD ± 11), and the posterolateral to 50% (± 17). CONCLUSION: This study demonstrates the efficacy of instrumented distraction when attempting surgical visualization of the distal tibial plafond articular surface. Knowledge of approach specific articular surface visibility may assist the surgeon in choosing the appropriate approach(es) based on case-specific distal tibial plafond fracture patterns. LEVEL OF EVIDENCE: IV, cadaver study.

Influence of X-rays and gamma-rays on the mechanical performance of human bone factoring out intraindividual bone structure and composition indices.

Doses of irradiation above 25 â€‹kGy are known to cause irreversible mechanical decay in bone tissue. However, the impact of irradiation doses absorbed in a clinical setting on the mechanical properties of bone remains unclear. In daily clinical practice and research, patients and specimens are exposed to irradiation due to diagnostic imaging tools, with doses ranging from milligray to Gray. The aim of this study was to investigate the influence of irradiation at these doses ranges on the mechanical performance of bone independent of inter-individual bone quality indices. Therefore, cortical bone specimens (n â€‹= â€‹10 per group) from a selected organ donor were irradiated at doses of milligray, Gray and kilogray (graft tissue sterilization) at five different irradiation doses. Three-point bending was performed to assess mechanical properties in the study groups. Our results show a severe reduction in mechanical performance (work to fracture: 50.29 â€‹± â€‹11.49 Nmm in control, 14.73 â€‹± â€‹1.84 Nmm at 31.2 â€‹kGy p â€‹≤ â€‹0.05) at high irradiation doses of 31.2 â€‹kGy, which correspond to graft tissue sterilization or synchrotron imaging. In contrast, no reduction in mechanical properties were detected for doses below 30 â€‹Gy. These findings are further supported by fracture surface texture imaging (i.e. more brittle fracture textures above 31.2 â€‹kGy). Our findings show that high radiation doses (≥31.2 â€‹kGy) severely alter the mechanical properties of bone. Thus, irradiation of this order of magnitude should be taken into account when mechanical analyses are planned after irradiation. However, doses of 30 â€‹Gy and below, which are common for clinical and experimental imaging (e.g., radiation therapy, DVT imaging, CT imaging, HR-pQCT imaging, DXA measurements, etc.), do not alter the mechanical bending-behavior of bone.

Long-term Follow-up and Histological Correlation of Peripheral Nervous System Alterations in Neurofibromatosis Type 2.

PURPOSE: To examine long-term alterations of the dorsal root ganglia (DRG) and the peripheral nerve in patients with neurofibromatosis type 2 (NF2) by in vivo high-resolution magnetic resonance neurography (MRN) and their correlation to histology. METHODS: In this prospective study the lumbosacral DRG, the right sciatic, tibial, and peroneal nerves were examined in 6 patients diagnosed with NF2 and associated polyneuropathy (PNP) by a standardized MRN protocol at 3 T. Volumes of DRG L3-S2 as well as peripheral nerve lesions were assessed and compared to follow-up examinations after 14-100 months. In one patient, imaging findings were further correlated to histology. RESULTS: Follow-up MRN examination showed a non-significant increase of volume for the DRG L3: +0.41% (p = 0.10), L4: +22.41% (p = 0.23), L5: +3.38% (p = 0.09), S1: +10.63% (p = 0.05) and S2: +1.17% (p = 0.57). Likewise, peripheral nerve lesions were not significantly increased regarding size (2.18 mm2 vs. 2.15 mm2, p = 0.89) and number (9.00 vs. 9.33, p = 0.36). Histological analyses identified schwannomas as the major correlate of both DRG hyperplasia and peripheral nerve lesions. For peripheral nerve microlesions additionally clusters of onion-bulb formations were identified. CONCLUSION: Peripheral nervous system alterations seem to be constant or show only a minor increase in adult NF2. Thus, symptoms of PNP may not primarily attributed to the initial schwannoma growth but to secondary long-term processes, with symptoms only occurring if a certain threshold is exceeded. Histology identified grouped areas of Schwann cell proliferations as the correlate of DRG hyperplasia, while for peripheral nerve lesions different patterns could be found.

New beginnings in post graduate medical education. Latin American Medical Education Leaders Forum / Nuevos comienzos en la educación médica de postgrado. Foro Latinoamericano de Líderes en Educación Médica

Introduction: The consequences of the Covid-19 epidemic have been catastrophic for Latin America in 2021. This study explores experiences, lessons learned, and practice changes during this critical time in post-graduate medical education in Latin America. Me-thods: A panel of 53 post-graduate medical education leaders from 8 Latin American countries and Canada was invited to participate in the 2021 Latin American Medical Education Leaders Forum to share their experiences, lessons learned, and main educational practice changes given the Covid-19 pandemic scenario. Participants were selected following a snowball technique with the goal of obtaining a diverse group of experts. Small group discussions were conducted by bilingual facilitators based on a semi-structured questionnaire. The plenary session with the main conclusions of each group was recorded and fully transcribed for a thematic analysis using a framework methods approach. Results: Participants ́ profiles included 13 experienced clinician-educators, 19 program directors, and 23 deans or organizational representatives. Seven specific themes emerged. They followed a pattern that went from an initial emotional reaction of surprise to a complex collective response. The responses highlighted the value of adaptability, the application of new digital skills, a renovated residents' protagonism, the strengthening of humanism in medicine, the openness of new perspectives in wellness, and finally, an unresolved challenge of assessment in medical education in a virtual post-pandemic scenario. Conclusion: A diverse panel of medical educators from Latin America and Canada identified changes triggered by the Covid-19 pandemic that could transform postgraduate medical education in the region.

Introducción: la pandemia de Covid-19 ha tenido consecuencias catastróficas para América Latina en el año 2021. Este estudio explora las experiencias, lecciones aprendidas y nuevas prácticas surgidas durante este crítico período en la educación médica de postgrado en América Latina. Métodos: un panel de 53 líderes de 8 países de América Latina y Canadá fue invitado a participar en el Foro Latinoame-ricano de Líderes en Educación Médica 2021 para compartir sus experiencias, lecciones aprendidas y cambios de prácticas educativas en el escenario de pandemia. Los participantes fueron seleccionados mediante la técnica de bola de nieve con el objetivo de obtener un grupo diverso de expertos. El Foro incluyó discusiones de pequeños grupos conducidos por facilitadores bilingües basadas en un cuestionario semiestructurado. La sesión plenaria con las principales conclusiones de los grupos fue grabada y transcrita para el análisis temático posterior utilizando la metodología de marco analítico. Resultados: el perfil de participantes incluyó 13 experimentados edu-cadores, 19 directores de programa y 23 decanos o representantes institucionales. Siete tópicos emergieron durante la discusión. Ellos siguieron un patrón que transitó desde una reacción emocional de sorpresa por la pandemia hasta una respuesta colectiva compleja. Las respuestas enfatizaron el valor de la adaptabilidad, la aplicación de nuevas habilidades digitales, un renovado protagonismo de los residentes, el fortalecimiento del humanismo en medicina, la apertura a nuevas perspectivas de bienestar y, finalmente, un desafío no resuelto respecto de la evaluación en educación médica en escenarios de pandemia. Conclusión: un panel diverso de educadores médicos latinoamericanos y canadienses identificó cambios claves gatillados por la pandemia de Covid-19 que pueden transformar la educación médica de postgrado en la región.

Costal Cartilage Calcification: Prevalence, Amount, and Structural Pattern in the General Population and Its Association with Age: A Cadaveric Study.

Importance: Costal cartilage calcification (CCC) of the cartilage graft, commonly used in reconstruction of nasal/auricular deformities, can cause poor surgical outcome, but structural and quantitative analyses are lacking. Objective: To compare the prevalence, amount, and structural pattern of CCC from individuals by gender and age, as measured by digital contact radiography. Design, Setting, and Participants: This is a cross-sectional cadaveric study (n = 92) of the seventh rib cartilage. CCC prevalence/amount/structural pattern (central [c]/peripheral [p]/diffuse [d]) was analyzed within three age groups: I (<40 years), II (40-70 years), and III (>70 years). Main Outcomes and Measures: Qualitative and quantitative CCC analyses were set in relation to gender/structural pattern/age. Results: CCC prevalence was gender independent (96.7%) and occurred in c/p/d: 12.4%/22.4%/65.2%. Structural CCC pattern differed between age groups (I: 80%; c/p/d: 26.7%/46.6%/6.7%; II: 100%; c/p/d: 18.0%/30.8%/51.2%; III: 100%; p/d: 2.6%/97.4%). The mean CCC amount (9.1%) was gender independent and showed a significant correlation with age (p = 0.001). The mean amount showed a significant difference between the structural pattern [d/p: 3.3 times higher (p = 0.006), d/c: 7.7 times higher (p < 0.001)] and age groups (I/II/III: 6.4/8.5%/10.9%), whereby the amount was higher in groups II (factor: 7.4; p < 0.001) and III (factor: 16.5; p < 0.001) compared with group I. Conclusions: These data show an age-/gender-independent high CCC prevalence in the general population (96.7%). CCC already occurred in young donors (<40 years) with a not negligible amount (6.4%). CCC increased with age and structural analysis showed a gender-/age-specific pattern, whereby males were prone to peripheral/females to central CCC. Diffuse CCC was observed as an age-independent sign for high CCC levels.

Landscape of T-cell repertoires with public COVID-19-associated T-cell receptors in pre-pandemic risk cohorts.

OBJECTIVES: T cells have an essential role in the antiviral defence. Public T-cell receptor (TCR) clonotypes are expanded in a substantial proportion of COVID-19 patients. We set out to exploit their potential use as read-out for COVID-19 T-cell immune responses. METHODS: We searched for COVID-19-associated T-cell clones with public TCRs, as defined by identical complementarity-determining region 3 (CDR3) beta chain amino acid sequence that can be reproducibly detected in the blood of COVID-19 patients. Of the different clonotype identification algorithms used in this study, deep sequencing of brain tissue of five patients with fatal COVID-19 delivered 68 TCR clonotypes with superior representation across 140 immune repertoires of unrelated COVID-19 patients. RESULTS: Mining of immune repertoires from subjects not previously exposed to the virus showed that these clonotypes can be found in almost 20% of pre-pandemic immune repertoires of healthy subjects, with lower representation in repertoires from risk groups like individuals above the age of 60 years or patients with cancer. CONCLUSION: Together, our data show that at least a proportion of the SARS-CoV-2 T-cell response is mediated by public TCRs that are present in repertoires of unexposed individuals. The lower representation of these clones in repertoires of risk groups or failure to expand such clones may contribute to more unfavorable clinical COVID-19 courses.